Provider Demographics
NPI:1912996257
Name:JACKSON, CANDY L (RD)
Entity Type:Individual
Prefix:
First Name:CANDY
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:505 E NORTH FOOTHILLS DR
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99207-2101
Mailing Address - Country:US
Mailing Address - Phone:509-483-7535
Mailing Address - Fax:509-483-9460
Practice Address - Street 1:1803 W MAXWELL AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-2831
Practice Address - Country:US
Practice Address - Phone:509-325-5502
Practice Address - Fax:509-325-9839
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2009-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00001765133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered